What Makes Doctors Happy

The Rand Corporation recently published a study of determinants of physician professional satisfaction, and their implications for patient care. One of the “most novel and important findings” related to electronic health records (EHRs).

The study found that EHRs affected physician satisfaction both positively and negatively. Physicians like the idea of EHRs, and appreciate their “promise” to improve patient care and thus professional satisfaction. However, the current reality of EHRs significantly detracted from physician satisfaction for multiple reasons,including, “Poor EHR usability, time-consuming data entry, interference with face-to-face patient care, inefficient and less fulfilling work content, inability to exchange health information between EHR products, and degradation of clinical documentation.”

I can personally testify to the validity of these findings. I have had the opportunity as a family practice doc to work extensively with two EHR systems. One is considered the “Cadillac” of EHRs, and the reputation fits: a bloated, lumbering, energy-guzzling EHR with lots of bells and whistles and a hefty price tag. The other one—well, let’s just say that using it, one gets the impression that the programmers made sure there were no physicians within 100 miles of them who might contaminate their EHR design with concepts of how actual physicians function.

Both of these EHRs are certified for something called “Meaningful Use.” This is a set of practices that EHRs must be capable of, and physician offices and hospitals have to implement, in order to receive bonus payments from the federal government and avoid penalties. The practices include things like E-prescribing, providing patients with an electronic copy of their health information, and generating patient lists for specific conditions.

But some things are absent from the requirements for Meaningful Use, like usability, and doesn’t detract from patient-physician interactions. A new report documents what most doctors already feel: that increased use of EHRs means less face-time with patients. For many if not most physicians, it means lots of time gazing into a screen and keyboarding that used to be spent face-to-face with patients. We spend time tending charts that used to be spent tending patients. I can confidently assert that most doctors did not go into the clinical practice of medicine because they prefer data-entry over relationships with patients; but this is what the current generation of EHRs has handed us.

The federal government defines “Meaningful Use” as “Use of EHRs in a way that positively affects patient care.” Positive effects on patient care can (theoretically, at least) come about by the data storage and manipulation capabilities that computers offer. But if they come about at the expense of that which is central to every human relationship—looking into the other’s face, body language that says, “What you are expressing to me is so important that I will give you my complete attention,” not multitasking—then perhaps the negative effects have overbalanced any theoretical positive effects. One of the dangers of EHRs is the old “To a patient with a hammer, everything looks like a nail” conundrum; to a person with a computer, everything looks like data. When we define “Quality medical care” solely in terms of what we can count and measure, when we value data over relationship, then “Meaningful Use” becomes a meaningless slogan.

 

Please don’t allow me to kill people: an open letter to Scott Adams

(Last Saturday, Scott Adams, the creator of the brilliant comic strip “Dilbert,” wrote in his blog a raw piece about physician-assisted suicide, which has created something of a stir. If you wish to read it, it is here; but I warn you, it is not pleasant reading, and it is full of profanity.)

Mr. Adams,

My deepest, deepest condolences. I don’t know you, but I am a Family Physician, and I have stood more times than I can count at the bedsides of people going through situations similar to your father’s. I have sat in too many rooms with families as their loved ones have withered away; too many times, I have been unable to offer healing, but only comfort, support, presence, and respect for the dying and his or her family.

Please don’t ask me to offer more than that. I know your blog post was written in the midst of “hideous unpleasantness,” and I can pardon your wish for me to die a slow, horrible death because I am opposed to using my power to kill people. But such extreme frustration, grief, and anger as you are experiencing is not in itself an argument for giving one class of people the right to kill others.

A long time ago, we doctors did kill people. We with the power to heal have always had the power to kill, and at one time we were allowed to use both powers indiscriminately. We were salesmen, technicians, offering whatever the customer wanted, whatever the market would bear.

But then someone, or maybe it was a group of people, who assumed the name “Hippocrates,” came out and said, “No more. We will not use our power to kill people. We know that Power can be used for good. But Power by its very existence begs to be used, and it knows no distinction between good and bad uses. We are well-meaning, but we know we are flawed. Therefore, we will place the most stringent restraints we know on our Power: we will not use our Power for killing.” And it was at that moment that we stopped being technicians and became Professionals.

But our record isn’t perfect. As recently as the middle of the last century some of our number in Germany thought we could safely use our Power to kill for beneficial purposes. And more recently, our colleagues in a few European countries — and now a few of our own states — have been given the go-ahead to use our Power (oh, so much greater now than in Hippocrates’ time) for just the purpose you advocate: to actively end a person’s life. And I must gently dispute your assertion that such policies are working “with little problems.” On the contrary, the problems those policies are facing are huge ones.

So please, don’t ask the government to give me the power to kill. I am human, like you, and, even with the best of intentions, I can’t properly handle such power. You can ask me not to abandon my dying patients. You can ask me to sit at my dying patients’ bedsides and weep at their funerals. You can ask me to do whatever I can to help their families. You can ask me to stop using unwelcome powers of healing that serve no other purpose to keep bodily functions going, and I will gladly comply; and I will use every bit of power within my reach to help alleviate pain, short of killing the sufferer. I will do it all in “com + passion,” which literally means “suffering with.”

But please don’t ask me to end suffering by using my Power to do away with the sufferer. Because there are just some things a Doctor shouldn’t do.

 

Providing incentives for unethical behavior

“Well, you could tell the patient that if he doesn’t do what you’re advising him to do, then you won’t be able to see him as his doctor anymore.”

I heard this statement recently. Is this an ethical way for a physician to approach a patient who doesn’t follow her advice? Or a patient whose behavior might be considered self-destructive?

I write as a primary care physician, and while there may be situations where the aforementioned strategy would be acceptable, I am loath to take such an approach. Very often the relationship between patient and physician itself is healing, and that relationship provides a space for further healing to take place. Dismissing the patient from the relationship eliminates whatever chance there might be for the physician to have a beneficial effect on the patient’s health in the future. (Not only that, it borders on manipulation.)

But a movement is afoot that may insidiously influence physicians to take just such an action. This movement is known by various names: pay-for-performance or “P4P,” quality improvement, aligning incentives. Traditionally, doctors have been paid according to the amount of work they do or time they spend caring for patients. Under P4P, they are paid according to how well they perform on certain “quality indicators.” Higher performers get bonuses; in some instances, lower performers are penalized.

The quality indicators take different forms. Some measure how well a physician follows certain guidelines: for instance, what proportion of his heart attack patients are sent home from the hospital with a certain type of medication, or what percentage of his patients with diabetes have certain tests ordered.

But some indicators measure how well a physician’s patients are doing: for instance, how many of her patients get their blood pressure under control, or what proportion of her patients with diabetes reach certain blood sugar targets.

These latter indicators tie a physician’s pay to factors that are essentially beyond her control. A physician can prescribe medications and recommend exercise and dietary changes; she cannot force her patient to adhere to her treatment. Thus, it may be financially disadvantageous for her to continue to have patients as part of her patient panel who won’t — or can’t — do what she recommends. It will be to her advantage to have only the healthiest people as patients. Thus, the perverse incentive to discharge from a physician’s care those who need it the most.

As part of health care reform, physician payment must be reformed, and physicians should be accountable for the care they give. But any scheme that penalizes them for factors beyond their control, that provides disincentives for them to care for the sickest of these, is wrong. Physicians should refuse to participate in any program of pay-for-performance that has the potential to become pay-for-unethical-behavior.

Thoughts on varied subjects: commercial surrogacy, professionalism, and Obamacare

A potpourri of stories from this week that prompted bioethical musings, in no particular order . . .

The BBC News website ran a fascinating, heartbreaking story this week about women in India who are paid to gestate other women’s babies: commercial surrogacy, a billion-dollar-a-year industry in India. The main figures in the story — a woman named Vasanti living in a dormitory for commercial surrogates, who is carrying a baby for a Japanese couple; and the doctor who runs the IVF clinic and dormitory — spend much of the story talking about how positive the practice of surrogacy is. Thus it is jarring — and revealing —  to get to the last sentence in the story, where Vasanti says, “. . .we want a good future. That’s why we [did] this, and not in my entire life do I want my daughter to be a surrogate mother.” (Italics mine)

***

Last week’s JAMA ran a narrative by Gordon Schiff, MD, which begins,

It’s 5 PM on a Friday afternoon. After 2 hours on the telephone trying (and failing) to get her insurance plan to pay for her medication refill, I reached into my pocket and handed the patient $30 so she could fill the prescription. It seemed both kinder and more honest than sending her away saying, “I’m sorry I can’t help you.” While I hardly expected a commendation for such a simple act of kindness, I was completely surprised to find myself being reprimanded for my “unprofessional boundary-crossing behavior” after the resident I was supervising shared this incident with the clinic directors.

(If you have a JAMA subscription you can read the whole thing here, otherwise it has been reposted for free  here.) Dr. Schiff’s reflections on this incident are eloquent and worth reading and pondering. From the perspective of a Christian physician who also works with the underserved, I am saddened at how far our profession strays from its moral foundations when  a detached, medicine-as-business model replaces the self-giving care that Christ modeled.

***

You may have missed it, but new provisions of the enormous law affectionately known as “Obamacare” went into effect this week with the beginning of open enrollment and the opening of online insurance marketplaces. The new law is extremely complex and promises to raise health insurance costs for many, including myself, at least in the short term. Lots of people are complaining about it, some more savagely than others. Many of my colleagues and patients have bemoaned it, and with good reason. But there is one group who have not complained to me about it at all: my patients who do not have, and until now have not been able to afford, health insurance.

First, do (no harm)

A fascinating, troubling article in the August Mayo Clinic Proceedings examines ten years of research articles from the New England Journal of Medicine (NEJM), perhaps the most prestigious and highest-impact medical journal around. During that period of time, the authors found 363 articles in the NEJM that described studies which tested an established medical practice to see whether it was actually helpful or not; of those, 146 (40%) found that the practice in question was either no better than doing nothing, or worse than doing nothing. An accompanying editorial asserts that “. . . ineffective, harmful, expensive medical practices are being introduced more frequently now than at any other time in the history of medicine. Under the current mode of evidence collection, most of these new practices may never be challenged.”

Our ability to do things to people has run far ahead of our ability to evaluate or think ethically about what we do. This doesn’t apply just to high-profile procedures like IVF and genetic testing, but also to more mundane procedures such as the treatment of urinary tract infections, inner ear infections, allergies, and asthma. In a techno-medicine world that views the human mechanistically, places starry-eyed (and frequently unwarranted) faith in medical technology, and sees all human problems as techno-medical problems that need a technical medical intervention, these results are perhaps to be expected. Ominously, they will likely only worsen.

A reasonable solution would be to wait and consider more thoughtfully and thoroughly our interventions — procedures, tests, drugs — before we foist them onto an unsuspecting populace. But to even suggest such a thing in some circles is to elicit rolled eyes and to be labeled an obstructionist, or a technophobe, a Luddite afraid of progress (as well as economically unrealistic). However, as we gain increasing power to alter the human organism, our potential to harm will increase proportionally. When it comes to power that we do not yet know how to use wisely, we should take as our example Frodo Baggins, and realize that in these cases, as in so many others, the solution to the problem of power is to refuse to use it.

More questions than answers about the classification of obesity as a disease

So the AMA has voted and decided that obesity is a disease. Good or bad? Right or wrong?

The answer to those questions is rooted in what we mean by disease. Is there an objective definition of disease? Is the concept of disease just a social construct?

The answer will also be affected by what we think of the phenomenon of medicalization, the progressive taking of human experience and turning it into something for medical treatment. Common human experiences like pregnancy and childbirth and bereavement have been converted into disease states that are then eligible for the full-court press of medical tests and treatments. This will certainly happen with obesity. A day after the AMA voted, the “Treat and Reduce Obesity Act” was introduced in the Senate and House of Representatives. The bipartisan bill would require Medicare to cover more obesity treatment costs. A good thing?

How do the one-third of Americans react who are obese and suddenly find themselves diseased? I have many patients, otherwise quite happy and hearty, who find that their lives have been somehow marred and diminished when they have a test of their bone density and it shows they have osteopenia, or they have a blood test that shows they have  hyperlipidemia (how’s that for a scary-sounding condition!); this despite the fact that their health is exactly the same as it was before they had the test. Now in fact, these diagnoses are not diseases. They are risk factors for actual diseases like hip fractures and coronary artery disease (although the vast majority of people with these risk factors will never develop the associated diseases), but they do not in-and-of-themselves cause any dis-ease, or lessening of ease — unless the patient starts to understand himself as “diseased,” with all of the treatments and drugs and anxiety thereunto appertaining. Is obesity a disease? Or by calling it a disease, do we just make lots of otherwise well people feel diseased?

What about the contribution that is made to obesity by the ubiquity of certain golden arches and their copycats, and the ever-enlarging television screens that beckon us to seat ourselves upon our couches? What if anything does labeling obesity a disease do to affect the pervasive marketing and spread of such obesity-promoters?

I don’t have answers, and I don’t think anyone else does. I hope that the AMA thought through the potential intended and unintended effects of their action. And I hope that the result of this vote is that more people actually end up healthier, and not just that more people end up being treated with drugs and gastric bypass surgeries.

Euthanasia Week

Last week was “one of those weeks” in the world of small animal veterinary medicine. Somehow all my cases that had been “circling the drain,” as we so elegantly put it, finally were pulled into its vortex, and we had a wave of euthanasia sweep through my practice. Three animals in renal failure in one day, a congestive heart failure, several cancer patients: the usual supects. It is a challenge to keep your spirits up in veterinary medicine as you hasten the passing of the sick and dying, even as you maintain clinical distance. Each case was different, but there was a certain consistency to what I did, maintaining faithfulness to my oath to relieve animal pain and suffering, through euthanasia if that was the only way to do so successfully. By Friday evening, as I placed my umpteenth (it seemed) fatal overdose of pentobarbital into a cephalic vein catheter while tearful family members held the pet they had raised from a puppy or kitten, or rescued from a shelter, or a dozen other stories, I began to think about this process in the context of human beings. For most people, this very difficult, but expected and necessary, part of my profession is well within the ethical boundaries in relation to animals. What if it becomes ethically permissible in the human medical profession someday? What patterns from my experience may be expected to carry over?

The comparison is imperfect, of course (and, indeed, I hope it would remain so no matter what!). Relationships with animals do not carry the baggage, for good or ill, of our human relationships. But people with their dying pets faced the decision seriously, with a desire to know the “right time,” when a cure was impossible, quality of life issues were substantially diminished, and their pets appeared to be suffering. (As a brief excursus, I don’t know how or if animals suffer; that seems to suggest a level of sophistication that few, if any, nonhumans have, including levels of physical, mental and spiritual dysfunction. That said, a pet euthanasia consultation is rarely a teachable moment for such philosophical sublimities and I just let them know that their pet may be suffering, or at risk of suffering, if they are just in awful condition.)

Most people look to me to give a green light to their choice, perhaps to nudge them past the guilt of a decision. “What would you do if she was your dog,” is asked of me daily, last week by a young married couple clutching an old beagle with inoperable bladder cancer and in end-stage kidney failure. That answer was easy. But they wanted my response to give ethical license for their choice. Legally, animals are “property,” the possessions of their human owners; we even call our clients the “owner” of their pets. Yet people look to us for moral guidance on when to end the life of their property. If human euthanasia is normalized, much more is at stake, and physicians will assume my role. I take comfort that I can provide peace and closure by reassuring my clients that their pet will be better off if we don’t force her to go to the bitter end. I am chilled to think of the comfort that a physician could similarly take in easing the decisions of those left behind to avoid the bitter end for their own family members. My euthanized patients don’t send me heartwarming, career-affirming “Thank You” cards; their families sure do.

I also noted a real, but subtle, dynamic in my staff, one that I think translates to human caregivers as well. My technicians and ward attendants could see full well that these patients would not get better. They heard me pronounce grave prognoses. They knew the patients in their care were dying, and they would find themselves frustrated with the pet owners that tarried on their decision to euthanize. The staff of veterinary hospitals is overflowing with idealists that advocate strongly for their animal patients. Without knowing it, my staff’s body language showed frustration and resignation, and those making the decision could sense the subtle pressure.

Certainly we see nurses and others in the ICU or in nursing homes that advocate for halting treatment they genuinely feel is burdensome to the patient and futile to recovery. Watching a patient slowly die is emotionally and intellectually exhausting. As sad as my staff is to lose a pet in our care, we all know the sense of relief that we feel when the call for euthanasia is made. We’ve usually stopped feeling guilty when we know we’ve done everything we can and that we can hasten the end. It is peaceful and quick, gentle and painless, which natural death so often is not. If human euthanasia is acceptable, expect this same subtle pressure and eventual sense of relief among hospital staff members, too.

This week is better (the positive aspect of losing so many of the moribund in one week is that the circle of life usually swings back the next). But I can’t help but think about the possibilities that the future holds, where human euthanasia is acceptable and even embraced. No, animals are not people ontologically-not yet, at least. But maybe I have seen the future for human medicine from my own vantage point as a veterinarian, and it should concern us all.

The Profession that Was

Once upon a time in a land far away, there existed a profession called “medicine,” a profession governed by internally derived standards and values, a profession that relied on both scientific data and experiential knowledge and judgment, a profession that focused on providing excellence in the care of others…
Last week I received a call from “utilization review” concerning the “hospital status” of a woman on whom I had just performed a vaginal hysterectomy by means of morcellation due to its size. The call challenged my decision to admit her for post-operative recovery.
Over the past 25 years we have gradually reduced the length of stay for our post-surgical (hysterectomy) patients from 5-7 days to 1-2. But the current impetus–mandated by insurance reimbursements and led by the governmental agency of the CMS (Center for Medicare-Medicaid Services)—is to require that hysterectomies be performed as an “outpatient” procedure. This entails discharging the patient hours after removal of an intra-abdominal organ with significant collateral circulation. As a default practice, such a mandate is unreasonable and unacceptable. It fails to consider the many contingencies of the individual patient and procedure for which physician judgment is still required.
At the risk of being too graphic, when a vaginal hysterectomy is performed, a major organ is removed through a relatively small orifice, compromising visualization of the surgical field. Inadequately secured blood vessels can retract into the pelvic sidewalls, out of sight, creating a risk of significant post-operative intra-abdominal hemorrhage. Fortunately, such risks materialize infrequently, but the risk still exists and requires a reasonable period of post-operative monitoring and assessment for the safety of the patient. For such bleeding, if it occurs, is potentially disastrous, even more so if the patient is not in the facility.
Over the past decade these same agencies have also become obsessed with pain control for hospitalized patients, developing and utilizing “visual analogue scales” (smiley faces) in an attempt to quantify the subjective and unquantifiable, and insisting that post-surgical patients be “pain-free,” an unreasonable expectation to begin with. Yet now it is proposed that patients be sent home with anesthesia-induced and pain-induced nausea and vomiting that prohibits them from taking their prescribed oral analgesics which results in more pain, more nausea, and more vomiting—a vicious cycle. Moreover, the increased intra-abdominal pressure that occurs with valsalva increases the risk of post-operative hemorrhage. As concerned as the accrediting bodies have been about pain control for hospitalized patients, there is no concern about the adequacy of pain control for patients who are discharged–it seems that it is then no longer their responsibility. But while it may no longer be the “responsibility” of the regulating agency, the pain and care of these patients is still my responsibility and concern.
Over the past few years this has resulted in “insurance-company-mandated-hospital-anxiety-over-lack-of-payment” induced game-playing over hospital status, games characterized by dishonesty and semantics. But these new rules, regulations, and games place physicians in the untenable situation of being morally and legally responsible for patient care that is legislated by a nebulous outside authority, one that lacks knowledge of the particular patient and/or procedural contingencies. Furthermore, as professionals, our calling is to be advocates for our patients and their care. Yet if we advocate for patients by refusing to abide by unreasonable and unacceptable regulations, especially in rural America, the hospitals in which we provide that care are penalized through the withholding of reimbursement and imposition of fines that threaten them with insolvency. Such a situation violates and undermines the concept of professionalism, which by its very nature is governed by internally derived values and standards, not externally imposed regulations.
Medicine is not a game, especially not a zero-sum game. It is a profession defined by excellence in its practices. Or at least it was. How is it that these “authorities” have assumed the right to dictate patient care without assumption of the correlative responsibility for any adverse consequences? I fear that we, ourselves, by shifting our focus from care to compensation, have let the fox into the henhouse. That fox has destroyed the profession…and I fear it is here to stay.